Emergency Departments (EDs) are an ideal setting for transmission of healthcare associated infections (HAI). Patient populations are diverse, including the chronically ill and the previously healthy, the rich and the poor, the young and the old, the immunocompetent and the immunosuppressed. Multiple patients are in close proximity, often separated only by curtains. Healthcare workers in the ED have varied levels of training, yet share a concern for immediate patient care needs as opposed to prevention, and a common environment that is crowded, interruption filled and chaotic. Questions such as whether and how to place central lines and urinary catheters and when to perform hand hygiene (HH) may seem less important than the immediate needs of multiple sick patients. Considering these factors, it is remarkable that so little attention has been paid to preventing HAI in U.S. EDs. There are approximately 5000 EDs in the U.S., and patients make over 190 million visits annually. Yet virtually nothing is known about U.S. EDs'practices to prevent central line associated bloodstream infections (CLABSI), catheter associated urinary tract infections (CAUTI), and to perform proper hand hygiene (HH). Therefore, we aim: 1) to use epidemiological methods to measure HAI prevention practices in U.S. EDs, focusing on CLABSI, CAUTI and HH. We hypothesize that, relative to intensive care units, EDs have implemented few programs to prevent these HAIs;2) To identify "positive deviants," EDs that are unusual because they have successfully implemented such programs, and use qualitative methods to identify motivations, barriers, and innovative solutions that these EDs developed to implement the interventions successfully;3) To develop a cost-effective toolkit addressing CLABSI, CAUTI and HH for dissemination to ED leaders. This toolkit will inexpensively deliver motivating background information and a simple set of interventions, which will help EDs to implement HAI prevention programs. We will conduct a representative national survey of U.S. EDs, using the National Emergency Department Inventory (NEDI, the only comprehensive inventory of all US EDs which we developed. This project will produce the first national estimate of ED adoption of HAI prevention strategies using the National Emergency Department Inventory (NEDI), the only comprehensive inventory of all US EDs, and will provide a cost-effective approach to translate proven infection control practices to EDs. PUBLIC HEALTH RELEVANCE: The emergency department is a unique cultural and organizational setting and constitutes an ideal ecosystem for the transmission of HAI. Yet this setting has been neglected in HAI prevention programs. We propose to quantify the extent to which HAI prevention programs have been implemented in U.S. EDs, to conduct systematic qualitative analysis of EDs that have implemented programs, and to develop a cost-effective toolkit for dissemination to ED leaders.